| Abstract|| |
Background: Sternal osteomylitis caused by mycobacterium tuberculosis is rare.
Method: During the past 27 years, 10 cases tubercular osteomyelitis of sternum were seen. All patients presented with a painful swelling over the manubrium sternii. The patients were treated by an antitubercular drug regime, aspiration of the cold abscess over the manubrium, and in three patients by curettage of the bony lesion.
Results: Follow-up has ranged from 2 years to 27 years. All the tubercular lesions had healed.
Conclusion: The diagnosis of manubrial lesions is easy because of their superficial location and the treatment of tuberculosis infection gave excellent results.
Keywords: Tuberculosis; Sternum; Osteomyelitis.
|How to cite this article:|
Thakker T, Prabhakar M M, Patel D A. Tubercular osteomyelitis of sternum. Indian J Orthop 2005;39:179-81
| Introduction|| |
Osseous lesions of manubrium sterni are not common , . Tuli and Sinha reported 14 cases of affection of sternum in a series of 980 cases of osteoarticular tuberculosis (1.5 %)  . Martini et al in a series of 125 patients  and Silva in a series of 219 case of skeletal tuberculosis did not have any patient with sternal involvement. In our search of published literature we found 79 cases of sternal involvement by tuberculosis.
| Method and Material|| |
Ten cases of tuberculosis of the manubrium sternii recorded by us during last 27 years are reported. There were 7 males and 3 females. There ages ranged from 11 years to 82 years. They presented with a painful swelling in front of the manubrium. The duration of symptoms was from 2 months to 1 year. On local examination the swellings were moderately tender, and boggy. The cold abscesses were fluctuant. General examination revealed one case of multifocal tuberculosis having tuberculosis of spine (D 8 -D 9 ), left hip and left 4 th metatarsal bone. X-rays of the sternum showed osteolytic lesion in the manubrium, with periosteal reaction in all cases. Spontaneous fracture of the sternum with tuberculosis was the presentation in one reported case. X-rays of chest were normal. In all patients pus could be aspirated and this was sent for Ziel-Nielson and Bactec examination. Other investigations included routine blood count, FNAC, serum electrophoresis and urine examination. In our cases diagnosis of tuberculosis was confirmed by one or more of these investigations. During the same period of study we encountered 8 other cases of swelling in front of the manubrium sternii due to other causes.
| Treatment|| |
All patients were put on an anti-tubercular regime consisting of rifampicin, isoniazid, pyrazinamide, ethambutol and streptomycin. Sparfloxacin and ciprofoxacin were the drugs in reserve. General supportive treatment in the form of multi-vitamins, proteins, anabolic hormone, iron and calcium were also given as needed. Cold abscesses were aspirated in all cases. Two patients did not respond to conservative regime. In them curettage of the bony lesion was carried out. No bone grafts were put in. The wounds were closed by suture of skin only.
| Results|| |
The patients were regularly followed up at monthly intervals at first and at 3 monthly intervals as the disease healed. They were followed for a minimum period of 2 years and the maximum of 27 years. The tubercular lesions in all the six patients healed. Operated patients were left with depressed scars. One girl had a small pit over manubrium. There has been no recurrence of infection.
| Discussion|| |
Isolated tuberculous osteomylitis without joint involvement commonly occurs in ribs, metacarpals, metatarsals, calcaneum, pelvis, skull and sternum. Infrequently, it can also occur in large tubular bones. The incidence is 2 to 3 % of all cases of osteoarticular tuberculosis. , . Lesions of the manubrium sterni are uncommon. Tuberculous infection settles in the sternum by a haematogenous spread from a lesion elsewhere.
There are reports of tuberculous infection after sternotomy for cardiac operations . It has to be remembered that Mycobacterium fortuitum may be recovered from sternotomy wounds of cardiac surgery  . Mycobacterium bovis infection of the sternum after a BCG vaccination has been reported  . Tuberculosis of sternum may complicate thalassaemia  . Patients with HIV may develop sternal tuberculosis  . Spontaneous fracture of the sternum with tuberculous infection has been reported  . The diagnosis of tuberculosis was made only after surgical exploration and pathological examination of the curetted material.
The tuberculosis of sternum might present with sternal and sternoclavicular pain, painful swelling, cold abscess, and parasternal sinus. As the swelling is superficial diagnosis is relatively early and easily confirmed by aspiration and histopathology and culture. Nearly one-third cases of Tuli and Sinha had a detectable lesion in other parts of skeletal or in lungs  . Others have also reported additional involvement of ribs, spine, axillary lymphadenopathy and involvement of testis. In contrast only two of our patients had multiple site involvement. Tuli and Sinha found abscesses and sinuses occurring earlier than radiological changes. In a series of 15 cased of sternal tuberculosis Shah et al found only 8 positive radiographs  . This we believe may be due to difficulty in obtaining a good quality X-ray of this region. A good lateral X-ray of the sternum coned over the lesion is needed for diagnosis. CT and MRI, where available, can detect changes much earlier than plain films. Jeung et al noted characteristic imaging appearances that allowed definite diagnosis  . Tuberculosis typically manifests at radiography and CT as osseous and cartilaginous destruction and soft tissue masses with calcification and rim enhancement.
Bacteriological diagnosis of tuberculosis is possible by studying the aspirate by Z-N staining, regular culture, or by BACTEC technique and polymerase chain reaction. Negative bacteriology at first does not exclude tuberculosis. Sometimes more than one effort at culture may be needed. Surgeons should, however, be aware that negative microbiology does not exclude a diagnosis of M. tuberculosis  .
Several treatment modalities are available: Anti-TB drugs only, or in addition aspiration of the abscess, open drainage of cold abscess and removal of granulation tissue, curettage of the bony lesion, partial resection of the sternum, and partial resection with reconstruction. In general treatment of tuberculosis of the manubrium by aspiration and adequate anti-tubercular drugs gives satisfactory results. Surgical treatment may be rarely justified for a doubtful diagnosis, a non-responsive case or for removal of a large sequestrum , .Three of our cases needed surgical curettage. Curettage of the bony lesion may suffice as in our three cases. Occasionally extensive resection is needed ,. However Lahiri et al reported only a 66.2 % success rate with high mortality and morbidity  . Reconstruction using muscle flaps may be needed after esection  . Antibiotic ofloxacin has been found effective for M. fortuitum infection of the sternotomy wounds  .
| References|| |
|1.||Richter R, Nubling W, Krause FJ. Isolated tuberculosis of the sternum. Nuclear Med. 1983; 139: 132 -35. |
|2.|| Ashour M, Pandya L. Tuberculosis of the sternum. Am Saudi Med 1990 ; 1075-9. |
|3.|| Tuli SM, Sinha GP. Skeletal tuberculosis-"Unsual" Lesions. Ind J Orthop. 1969; 3: 5-18. |
|4.|| Martini M, Adraj A, Boudjemma A. Tuberculous ostemyelities, a review of 125 case. Int Orthop. 1986; 10: 201-207. |
|5.|| Silva JF. Review of patients with skeletal tuberculosis at the University Hospital,Kulaa Lumpur, International Orthopedics[SICOT],4:79-81,1980. |
|6.|| Hajjar W, Logan AM, Belcher PR. Primary sternal tuberculosis treated by resection and reconstruction. Thorac Cardiovasc Surg. 1996; 44: 317-8. |
|7.|| Aggarwal B, Kamath S, Shatapathy P. Tuberculous sternal osteomyelitis and mediastinitis after open heart surgery. Ind Heart J. 1997; 49: 313 - 4. |
|8.|| Yew WW, Kwan SY, Ma WK, Khin MI, Mok CK. Single daily dose ofloxacin monotherapy for Mycobacterium fortuitum sternotomy infection. Chest. 1989; 96: 1150-2. |
|9.|| Simla S, Liedes E, Kinnmen P. Sternal abscess as a complication of BCG revaccination. Tubercle 198.; 69: 67 - 9. |
|10.|| Kataria SP, Avasthi R. Sternal tuberculosis in combination with thalassaemia. J Assoc Physic Ind. 1993; 41: 472. |
|11.|| Martors JA, Olm M, Miro JM, Mallotas J, Letang E, Brancos MA, Gatell JM, Soriano E. Chondrocostal tuberculosis in 2 heroin addicts infected with human immunodeficiency virus. Med Clin [Barc] 1989; 93: 467-70. |
|12.|| Watts RA, Paice EW, White AG. Spontaneous fracture of the sternum tuberculosis. Thorax. 1987; 42: 984 - 5. |
|13.|| Shah J, Patkar D, Parmar H, Varma R, Patankar T, Prasad S. Tuberculosis of the sternum and clavicle. Imaging findings in 15 patients. Skeletal Radiol. 2000; 29: 447-53. |
|14.|| Jeung MY, Gangi A, Gasser B, Vasilescu C, Massard G, Wihlm JM, Roy C. Imaging of chest wall disorders Radiographics. 1999, 19, 61737. |
|15.|| Stewart KJ, Ahmed OA, Laing RB, Holmes, JD. Mycobacterium tuberculosis presenting as sternal osteomyelities J R Coll Surg Edinb 2000, 45: 135 - 7. |
|16.|| Mathlouthi A, Ben M' Rad S, Merai S, Friaa T, Mestiri I, Ben Miled K, Djenayah F. Tuberculosis of the thoracic wall. Presentation of 4 personal cases and review of the Literature. Rev Pneumol Clin. 1998, 54 182-6. |
|17.|| Lahiri TK, Agrawal D, Gupta R, Kumar S. Analysis of status of surgery in thoracic tuberculosis. Ind J Chest Dis. 1998., 40,99-108. |
|18.|| Cheng Hw, Lee Hy, Chen HC. Reconstruction of upper chest wall defects with a function-preserving pectoralis major muscle flap: case report. Chang Keng I Hsueh Tsa Chih. 2000, 23 107-12. |
28, Shantikunj Society, Ramnagar,Sabarmati, Ahmedabad-380005
[Figure - 1], [Figure - 2], [Figure - 3]